Rethinking Bhopal A Definitive Guide to Investigating, Preventing, and Learning from Industrial Disasters 1st Edition by Kenneth Bloch ISBN 012803842X 978-0128038420
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ISBN 10: 012803842X
ISBN 13: 978-0128038420
Author: Kenneth Bloch
Rethinking Bhopal: A Definitive Guide to Investigating, Preventing, and Learning from Industrial Disasters is the go-to source for anyone seeking to learn how to improve process safety management (PSM) through applying fundamental asset reliability and incident investigation concepts.
The seeds that unified PSM on a global scale were planted in Bhopal, India on December 3, 1984. Since then, considerable progress has been made to protect both workers and communities from catastrophic industrial failures. Industry acknowledges its responsibility to create value with accrued operating experience and that using information received from previous failures is a direct way to prevent future incidents. With this principle in mind, Bloch evaluates modern references related to the Bhopal Disaster, using recognized industrial asset reliability and incident investigation concepts.
The practice of objective incident investigation offers a compelling insight into specific decisions and actions that resulted in history’s worst industrial disaster. Recording a fully transparent sequence of events promotes a personal sense of accountability for anyone involved in the manufacturing industry. Lessons learned can be immediately implemented by those with direct PSM, management, engineering, and operating responsibilities. Case histories demonstrate how patterns observed in the timeline leading up to the Bhopal Disaster can be detected in modern incidents and by recognizing these patterns in present-day processes avoids counterproductive operating decisions and unprecedented destruction.
This text is instrumental in helping existing organizations re-evaluate their own exposures and risks, and would be a valuable read for any member of a process safety management team. Rethinking Bhopal: A Definitive Guide to Investigating, Preventing, and Learning from Industrial Disasters provides an expansion of knowledge and understanding for the novice in PSM while also providing depth and application considerations to challenge more experienced industry professionals. Note: All royalties from this book go to the Process Safety Heritage Trust Scholarship at Lamar University in Beaumont, Texas, USA.
- Learn how to improve Process Safety Management (PSM) performance by applying fundamental asset reliability and incident investigation concepts
- Understand your personal role in detecting and preventing Loss of Primary Containment (LOPC) incidents before they occur
- Take immediate action to stabilize processes under your control while promoting a systematic approach to eliminating persistent failure mechanisms
- Includes case histories to helpfully illustrate how to detect potentially destructive patterns in your own organization
Rethinking Bhopal A Definitive Guide to Investigating, Preventing, and Learning from Industrial Disasters 1st Table of contents:
Part 1: Process Reliability
Chapter 1: Industrial Learning Processes
- The Bhopal Disaster
- Policies and Regulations
- The Process Safety Management Movement
- The Incentive to Change
- From Simplicity to Complexity
- Incident Prevention
- Investigation Reports
- Lessons for Us
Chapter 2: Equipment Reliability Principles
- Being in Control
- Break-Even Analysis
- Patents and Trade Secrets
- Process Flexibility
- Asset Protection
- Functional Combinations
- Managing Performance Loss
- Functional Failures
- Reliability Plans
- Reliability Analysis
- Justifying Design Changes
- Preventing Premature Failure
- Spare Assets
- Reliability Performance Metrics
- Mean Time to Repair
- Failure Rate
- Mean Time Between Failure
- The Human Condition
- Lessons for Us
Chapter 3: Incident Investigation
- The Normalization of Deviance
- Investigation Triggers
- Culture and Context
- Neutrality
- The Investigation Procedure
- Phase I: Front-End Loading
- Phase II: Pattern Matching
- Phase III: Closure
- Lessons for Us
Chapter 4: Role Statement and Fulfillment
- Industrial Amnesia
- Establishing Process Reliability Expectations
- Production Constraint Removal
- Tracking Performance Measures
- Developing Process Safety Skills
- Assessing Process Performance and Improvement
- Justifying Cases for Action
- Validating Performance Results
- Preserving the Value of Acquired Knowledge
- Cooperative Communication
- Supervision’s Responsibilities
- Lessons for Us
Chapter 5: Spent Caustic Tank Explosion: A Case Study in Inherently Safer Design
- Witness Statements
- Process and Asset Description
- Hazard Control
- Background
- Process Hazard Analysis Action Item
- Design Change
- Incident Investigation
- Design Defects
- Procedure Deviation
- Worker Interviews
- Warning Signals
- Ignition Source
- Evaluating Causes
- Functional Recovery
- Organizational Culture
- Lessons for Us
Part 2: Research and Development
Chapter 6: Inventing Solutions
- Event Description
- Technical Analysis
- Lessons for Us
Chapter 7: Product Manufacturing and Distribution
- Event Description
- Technical Assessment
- Lessons for Us
Chapter 8: Process Selection
- Event Description
- Technical Assessment
- Lessons for Us
Chapter 9: Industry Compliance
- Event Description
- Technical Assessment
- Lessons for Us
Chapter 10: Production Commitments
- Event Description
- Technical Assessment
- Lessons for Us
Part 3: Process Configuration
Chapter 11: Licensing
- Event Description
- Technical Assessment
- Lessons for Us
Chapter 12: Factory Construction
- Event Description
- Methyl Isocyanate Refining Still
- Methyl Isocyanate Storage Tanks
- Methyl Isocyanate Circulation and Transfer Pumps
- Methyl Isocyanate Refrigeration
- Methyl Isocyanate Vapor Management
- Vent Gas Scrubber
- Instrumentation, Gauges, and Alarms
- Technical Assessment
- Lessons for Us
Chapter 13: Process Hazard Awareness and Analysis
- Summary
- Technical Assessment
- Rundown Tank Node
- Hypothetical Scenario
- Risk Calibration
- Consequence Category
- Frequency of Consequence
- Independence
- Passive Protection
- Evaluating Double Jeopardy
- Human Intervention
- Lessons for Us
Chapter 14: Commissioning Phase
- Event Description
- Technical Assessment
- Lessons for Us
Chapter 15: Repeat Mechanical Seal Failures: A Case Study in Pump Reliability Improvement
- Acceleration Basics
- Detecting and Investigating a Vibration Problem
- Acceleration Limit
- Revisiting Reliability Growth Plots
- Unstable Hydraulics
- Casting Defects Suspected
- Applying Modern Hydraulic Selection Criteria
- Suction Recirculation
- Reliability Factor
- Busting Cavitation Myths
- Lessons for Us
Part 4: Operations and Production
Chapter 16: Management of Change
- Event Description
- Technical Assessment
- Lessons for Us
Chapter 17: Process Isolation and Containment
- Event Description
- Technical Assessment
- Lessons for Us
Chapter 18: Employee Participation
- Event Description
- Technical Assessment
- Lessons for Us
Chapter 19: Compliance Audits
- Event Description
- Technical Assessment
- Lessons for Us
Chapter 20: Process Optimization
- Event Description
- Technical Assessment
- Lessons for Us
Chapter 21: Maintenance Failure
- Event Description
- Technical Assessment
- Lessons for Us
Chapter 22: Human Error
- Event Description
- Technical Assessment
- Lessons for Us
Part 5: Lessons Learned
Chapter 23: Crude Unit Fire: A Case Study in Human Error
- Introduction
- Process Overview
- Event Description
- Investigation
- Inspection Results
- Interviews
- Integrity
- Closure
- Instinct
- Lessons for Us
Chapter 24: Reliability Commitment
- Lessons Learned
- What You Can Do
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